If you recall, we had a stubborn gentleman complaining of indigestion with a significant cardiac history. Considering the symptoms kept our patient awake, are highly suggestive of a coronary event, and we have uncompensated hypotension, we should have a keen interest on any ECG findings.

The rhythm appears to be regular, sinus in origin, rate of ~70 bpm, without ectopy. There is a fixed PR-interval of 0.2 s and a 1:1 association of P-waves to QRS complexes. The QRS is wide at 0.18 s, likely due to a bundle branch block. Normal sinus rhythm with a bundle branch block.

Evaluating the QRS complex in V1, we see it is wide and V1-positive confirming our suspicion of a bundle branch block. However, given the changes in leads I and V6, it is not a classic Right Bundle Branch Block. Instead we have a non-specific intraventricular conduction defect, or IVCD. A right axis deviation is present.

Pathologic Q-waves in the inferiolateral lead groups are consistent with our patient's history of multiple prior MI's, however, without a prior ECG it is tough to determine if these are not from a recent myocardial infarction.

The potential ST-depression in the septal leads may be reciprocal changes in the setting of a posterior MI. The patient's skin condition made acquisition difficult, but coupled with the patient's signs and symptoms it would be prudent to explore this possibility. Attempts could be made at the acquisition of a posterior view.

The interventricular conduction defect present may be an acute finding or it may be a baseline finding. Given the QRSd is around 0.18 s there is a non-trivial defect present. Without access to the patient's prior ECG's we are unable to determine its significance.

While examination of the 12-Lead ECG for this patient did not yield any acute findings, in conjunction with our patient assessment we have enough to form a differential diagnosis:

Acute myocardial infarction

Recent myocardial infarction

Congestive heart failure

Pulmonary embolism (albiet less likely due to symptoms)

However, any differential diagnosis for this patient is rendered moot by his stubborn desire to refuse transport!

The paramedics on this call rolled up their sleeves and got to work convincing this gentleman that his signs and symptoms were anything but normal. He begrudingly sat on the stretcher and consented to transport.

They placed him on O2 by nasal cannula, obtained IV access, administered a fluid bolus, and transmitted the 12-Lead ECG to a local STEMI receiving center. His blood pressure improved enough with fluid administration to allow nitroglycerin, which the patient said improved his discomfort.

Transmission of the patient's ECG was key in this case as the receiving facility determined acute changes were present.

The patient was taken directly to the cath lab where a 90% occlusion of the LAD, just proximal to a previous stent, was found. The lesion was ballooned and stented, and the patient was admitted to the CCU for recovery.

Some additional questions for discussion:

Why was this patient's hypotension uncompensated?

Are there any differentials we missed?

Why was indigestion left off the list of differentials?

11 Comments

Very throrough review of the case and findings Tom. I've got two questions for ya. First, do you have any info on what acute changes the hospital noted from his prior ECG? I'm very curious whether it was the Q-waves, IVCD, or non-specific ST and T-wave changes. Also, do you have any info on the duration of the patient's symptoms before calling EMS? Thanks, and as always, thanks for this wonderful resource.

Great case Christopher! i was wondering what your thoughts are about the rule of appropriate discordance in this case… i know you said it was not typical RBBB,which was noted, and the T waves are not appropriately discordant in the chest leads… any thoughts on that?

Dave B,
I noticed that as well, but the criteria assume RBBB/LBBB and outside of any frank changes in those leads I wasn't prepared to label them acute changes. The findings in V1-V3 are certainly concerning and given our patient's signs/symptoms it is worthwhile to watch them for any dynamic changes.

Looking back you're right! My apologies, I wrote the questions before I saw all the comments. I too was wondering if it was uncompensated hypovolemia or hypotension secondary to poor cardiac output. A good patient history should elicit good information on the patient's In's and Out's; regardless, we can agree this patient is due for a fluid challenge!

William Dillon60 year old male CC: Sudden cardiac arrestGreat case but it stopped short. It should continue. The patient was transferred to an experienced PCI center. Focused medical evaluation was performed in the ED and emergent cardiology consultation was obtained. Although there is not clear ST elevation on the 12 lead the interventional cardiologist knows the data that over 70% of VF cardiac…
2015-03-03 12:53:20

Sharon SinclairThe 12 Leads of Christmas: V3As a technician, I absolutely love how comprehensive these posts are. Although I do not have the advanced knowledge or understanding of a licensed provider, I try to absorb as much as I can from posts like these. Maybe one day I will muster the courage to transition to a more advanced position in cardiac…
2015-02-28 20:40:17

A visit to Johns Hopkins #EMSToday2015 | EMS 12 LeadEpisode #11 – Are we harming patients with oxygen?[…] might remember Mike from one of our most popular EMS 12-Lead podcasts Episode #11: Are we harming patients with oxygen? We finished up the night with food and adult beverages in the […]
2015-02-25 14:33:03

RolloThe Trouble with Sinus TachycardiaHad a pt today with a rate @ and around 160, it was indeed sinus tachycardia. The tachycardia was secondary to a stimulant which caused over stimulation of sympathetic nervous system ie sympathomimetic O.D. The treatment was fluid and a benzo. Problem solved.
2015-02-25 00:14:18

Jeff ReaderThe 12 Leads of Christmas: V3When looking at how the heart sits in the chest and how things are named remember they were probabily named during autopsys when the cadaver was on its back.
2015-02-24 16:55:04